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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 1 <br /> (IWO pages per tank) <br /> Page <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 1.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ S. TEMPORARY SITE CLOSURE <br /> fOHck.dam pry) ❑ T. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (SPeEBy reason-brlocsl use erxy) f5prvy cHrgs-brlocal use Pnly) ❑ 8. TANK REMOVED 4W <br /> BUSINESS NAME(Sema as FACILITY NAME w DBA-D"Business b) FACILITY 10 Y 1 <br /> L T � SITE IOP / QC.)�/ 4]1 �` S� GL� 6 ✓4 <br /> I.TANK DESCRIPTION <br /> TANK 10 TANK MANUFACTURER COMPARTMENTALIZED TANK Yes ❑ No <br /> II-Vei mmgals ww D+9e bnaN compaeMant <br /> foci <br /> DATE INSTALLED(YEARIMO) TANK CAPACITY IN GALLONS NUMBER Of COMPARTMENTS <br /> ADDITIONAL DESCRIPTION fForl Iuseomy <br /> II.TANK CONTENTS Y1s, 1 <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL [3 1. REGULAR UNLEADED Cl 2. LEADED Fr y' 1 <br /> (NmaMW.compNM PefmMum Typa) 18. PREMIUM UNLEADED [33. DIESEL O a�T Tr1EaLl�i <br /> ❑ 2. NOWFUEL PETROLEUM 111E MIDGRAOEUNLEADED ❑ 4. GASOHOL 04!X1 BLff <br /> ❑ 3. CHEMICALPRODUCT 1$linp <br /> COMMON NAME(Imm Nuamaw M4IINYS Inwnlorypagel Materials lnr.nfpry page) <br /> ❑ 4 HAZARGOUSWASTERntlWea <br /> USW Oq <br /> Ill.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ t SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ S. SINGLE WALL'MTK INTERNAL BLADDER SYSTEM <br /> (cn.cx om item oNy) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER <br /> TANK MATERIAL pNmary Nnk 1. BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ 5. CONCRETE 095. UNKNOWN <br /> (CHcx.Nan wry) ❑ 2 STAINLESS STEEL ❑4. STEEL CLAO WIFIBERGLASS ❑ 5 FRP COMPATIBLE WIIW%METHANOL [3 99, OTHER <br /> REINFORCED PLASTIC(FRPI <br /> TANK MATERIAL.fe[uWary IarIk ❑ I BARE STEEL 3. FIBERGLISSIPIASTIC ❑ a. FRP COMPATIBLE WIIW%METHANOL 095. UNKNOP <br /> fCnwx om Nem PNq ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASS ❑ 9 FRP NON-CORRODIBLE JACKET 099. OTHER <br /> REINFORCED PLASTIC(FRP) 010 COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING DATE INSTALLED <br /> OR COATING ❑ 1. RUBBER UNEP ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOVNJ4]] <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 8. UNLINED ❑99. OTHER Forlwsl use pnl J <br /> (CHEM CORROSION <br /> ) T� DATE INSTALLED <br /> OTHERO,*damo ON ❑ 1. MANUFACTURED GTHODIC ❑ 3. FlBERGLA55 REINFORCED PLASTIC ❑95. UNKNOWN 4]4 <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT ❑99. OTHER (fwlPEa/uae any) <br /> (Clteck.00..*) ❑ 2. SACRIFICIALANODE <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Fwbcalusam*) OVERFILL PROTECTION EQUIPMENT,YEAR INSTALLED <br /> (CM1ecx aO mal appry) 1. SPILL CONTAINMENT 1.ALARM 3, FILL TUBE SHUT OFF VALVE <br /> 2. DROP TUBE ❑ 2. BALLFLOAT ❑ 4. EXEMPT <br /> 3. STRIKER PLATE <br /> N.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK Chx aN hers J: IF DOUBLE WALL TANK OR TANK WITH BLADDER tem-11W: <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> 2. AUTOMATIC TANK GAUGING(ATG) ❑ S. VADOSE ZONE 2. CONTINUOUSINTERSTITIALMONITORING <br /> ❑ 3. CONTMUOUSATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ S. TANKTESTING <br /> BIENNIAL TANK TESTING ❑99 OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRAIOMAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL <br /> '.!IonsYea ❑No t <br /> ❑ <br /> Formerly SWRC9 Farm S <br /> CUPAFORM(4/99) _ <br />